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Background Improving health insurance coverage and retention in communities of color is a national priority and new approaches are needed. Objectives To describe 1) the formation of Insure Detroit, a community-based participatory research (CBPR) partnership aimed at addressing health insurance and Affordable Care Act (ACA) literacy challenges in economically disadvantaged areas, 2) the development of Insuring Good Health, a novel, multimedia, health information technology-focused intervention to address the health aims of the partnership, and 3) the evaluation plan for the intervention. Methods Insure Detroit, a partnership between researchers and community-based organizations, was established. Principles of CBPR were followed closely in the conduct of this project. The Insure Detroit partnership developed the intervention and evaluation plan through an iterative process. The Insuring Good Health intervention is multilingual and composed of a responsive website. It includes nine short, animated videos informed by storytelling techniques that communicate key learning points pertaining to health insurance navigation and use. Lessons learned Lessons learned included narrowing learning points for the intervention, balancing the volume of work to comply with the study timeline, and balancing the political climate with the development of the intervention. Conclusions The Insure Detroit partnership demonstrates that a CBPR approach can develop media-based health communications to address health insurance literacy. Our experiences highlight that CBPR principles that encourage shared decision making and co-learning can result in high-quality, innovative interventions that have the potential to resonate well with communities of color. more...

Confusion around health insurance reforms persist. The purpose of this study was to assess demographic differences in Affordable Care Act (ACA) and health insurance knowledge in a multi-ethnic urban sample. Data came from 243 adults from racial/ethnic communities. Participants were asked about elements of health insurance and the ACA. Generalized linear and logistic regression models were used to examine relationships between demographic predictors and knowledge domains. Female gender (p more...

The study of urban populations must be grounded in the realities of local communities. Much as many insights of urban health are generalizable to the health of cities worldwide, local knowledge both can and is necessary to guide action that can improve the health of urban populations. Community-based participatory research is an approach to research that has a particular role in both the study of urban communities and in developing interventions and policies that can improve the health of these populations. This chapter discusses the principles and strategies of community-based participatory research and how their applications can guide the study and practice of urban health towards achieving health equity. more...

Background. The U.S. uninsured rate has dropped significantly since the passage of the Affordable Care Act (ACA), yet insurance coverage remains lower in historically marginalized communities than in the overall population. New consumer engagement approaches that involve these populations are needed. The purpose of this study was to evaluate the effectiveness of the Insuring Good Health Intervention, a website and video series designed to improve engagement with health insurance and ACA reforms. The study was designed and implemented using a community-based participatory research approach. Method. We conducted a lagged-control cluster randomized controlled trial to evaluate Insuring Good Health with racially and ethnically diverse adults seeking services in medically underserved areas within the Detroit, Michigan metropolitan area. Outcomes were assessed at baseline and at 6 and 9 months postintervention, and including self-efficacy, knowledge, beliefs, and intention to seek help with insurance navigation and care. Results. Among 243 participants, mean age was 43.4 ( SD = 13) years, and all participants met federal guidelines for poverty. The study had an 86% response rate at 9-month follow-up ( n = 209). Compared with the lagged-control group, intervention participants had more positive beliefs concerning preventive care (estimate 0.51, standard error 0.16; p < .01), and intention to seek help with insurance navigation and care (estimate 0.43, standard error 0.17; p < .001) at 9-month follow-up. Hispanic participants benefitted the most from the intervention, including improved knowledge of health insurance eligibility over 9 months compared with other racial/ethnic groups (estimate −0.97, standard error 0.40, p < .01). Discussion. Insuring Good Health was associated with increased intention to seek help with insurance navigation and care, and improved beliefs around preventive care. Conclusions. Insuring Good Health has the potential to be an important consumer engagement tool to reduce disparities in health insurance coverage and care seeking. more...

Coverage and access have improved under the Affordable Care Act, yet it is unclear whether recent gains have reached those regions within states that were most in need of improved access to care. We examined geographic variation in Medicaid acceptance among Michigan primary care practices before and after Medicaid expansion in the state, using data from a simulated patient study of primary care practices. We used logistic regression analysis with time indicators to assess regional changes in Medicaid acceptance over time. Geographic regions with lower baseline ( more...

Policy and systems change is essential to attaining public health equity, and involving communities disproportionately experiencing health inequities is critical. Successful policy mobilization requires specific community capacities, many of which exist in marginalized communities but can be strengthened and amplified. Yet attention to strengthening capacity of communities historically excluded from the policy process has been limited. This study applies a community capacity framework to analyze Neighborhoods Working in Partnership (NWP), a multiyear, community-based participatory initiative to strengthen skills and capacity of Detroit residents to equitably engage with diverse partners in all aspects of the policy process. Findings indicate NWP strengthened key dimensions of policy capacity, including skills, participation, leadership, and community power. We discuss strengths and limitations of NWP, and implications for strengthening capacity of disenfranchised communities to engage in local policy action toward the long-term goal of community well-being and equity. "The most important thing about the training is knowing that I have power that will positively impact my neighborhood and that now I know how to use it." (Workshop participant) Background There is considerable evidence that stressors in the social and physical environment and lack of access to resources contribute to poorer health and widening racial/ethnic and economic inequities (Braveman, Cubbin, Egerter, Williams, & Pamuk, 2010; Israel et al., 2010; Link & Phelan, 1995; Schulz, Williams, Israel, & Lempert, 2002). Low-income urban communities and communities of color are disproportionately affected, for example, through exposure to deteriorated housing and neighborhood conditions such as blight and crime, and limited access to jobs and quality services and amenities that can help to protect health (Schulz & Northridge, 2004; Williams & Collins, 2001). These structural conditions are influenced by state and national as well as local and organizational policies, and so policy change is an important strategy to have a more sustained impact on community well-being (Phelan, Link, & Tehranifar, 2010; Williams & Jackson, 2005). Thus, addressing the underlying social determinants of health equity requires the capacity to work effectively with policy and decision makers to address factors such as housing, neighborhood conditions, education, and employment opportunities foundational to the attainment of public health. A successful policy advocacy campaign requires an essential set of skills or capacities (Freudenberg, Rogers, Ritas, & Nerney, 2005; Minkler, Vasquez, Tajik, & Petersen, 2008; Ritas, 2003). Successful models for influencing policy emphasize the need to engage communities that have historically been marginalized or excluded from this process (e.g., low-income communities, communities of color) in policy campaigns (Freudenberg & Tsui, 2014; Themba-Nixon, Minkler, & Freudenberg, 2008). Engagement of community members in policy change efforts can lead to increases in power through translation of concerns into concrete action and identification of policy solutions to issues inadequately addressed by current policy (Cheezum et al., 2013; Ritas, 2003; Roe, Minkler, & Saunders, 1995; Themba-Nixon et al., 2008; Themba, 1999). Many communities regularly engage in policy advocacy efforts, often with a great deal of skill and success. However, relatively few examples exist of initiatives designed to both build on and strengthen dimensions of community capacity, with particular attention to policy advocacy to address determinants of public health and equity (for exceptions, see Minkler, Vasquez, Chang, & Miller, 2009; Sharpe et al., 2015). The recognition that many of these capacities already exist within marginalized communities, and that they can be strengthened and amplified, is central to community-based participatory approaches to research and action, and underlies the efforts described here. … more...

Low-income people of color are at risk of remaining uninsured due to a variety of factors. This study examined Affordable Care Act (ACA)-related and other health insurance enrollment experiences, observations, navigation needs, and experiences maintaining health insurance coverage among low-income communities of color in an economically disadvantaged community (Metropolitan Detroit). We conducted nine focus groups (n = 87) between May and June 2015. Participants were recruited through community-based organizations serving our key populations of interest. Using an inductive thematic analysis approach, codes and themes were generated. Findings from six themes demonstrated that although health insurance is perceived as important, confusion and frustration persist around health plan benefits and coverage, eligibility requirements and key provisions of the ACA, and enrollment. Individuals face difficulties justifying the cost of health insurance. More focused insurance outreach efforts are needed to achieve the ultimate goal of improving the health of low-income communities of color. more...

Because of a strong tendency to “medicalize” health status problems and to assume that their primary solution involves medical care, policymakers often focus on increased financial and geographic access to personal health services in policies aimed at populations that are vulnerable to poor health. This approach has produced real public health gains, but it has neglected key social and economic causes of health vulnerability and disparities. Although access to care is a necessary component of population health, concerted policy action in income security, education, housing, nutrition/food security, and the environment is also critical in efforts to improve health among socially disadvantaged populations. more...

In 2001, virtually every child on Detroit's eastside was eligible for health coverage, yet approximately 3,000 children remained uninsured. The primary aim of the Eastside Access Partnership (EAP), a community-based participatory research collaboration, was to increase enrollment of uninsured children in state programs. To achieve this aim, one of the approaches that EAP is using is the innovative Learning Map© titled Choosing the Healthy Path, which was developed in collaboration with Root Learning, Inc. Although Learning Maps were originally developed to assist corporations in implementing strategic change, their integration of visualization and interactive dialogue incorporates Freirian principles of empowerment education, making them a viable option for providing meaningful learning opportunities for community residents. This article presents the collaborative process involving the University of Michigan, local community-based organizations, community members, and Root Learning consultants to develop a visual map that enables community residents to understand and overcome the barriers that prevent them from obtaining health insurance for their children. more...

The Affordable Care Act expands health insurance coverage to millions of Americans, but the availability of health care services for the newly insured population remains uncertain. We conducted a simulated patient (or "secret shopper") study to assess primary care appointment availability and wait times for new patients with Medicaid or private insurance before and after implementation of Michigan's Medicaid expansion in 2014. The expansion, which was made possible through a section 1115 waiver, has a unique requirement that new beneficiaries must be seen by a primary care provider within 60-90 days of enrollment. During a period of rapid coverage expansion in Michigan, we found that appointment availability increased 6 percentage points for new Medicaid patients and decreased 2 percentage points for new privately insured patients, compared to availability before the expansion. Wait times remained stable, at 1-2 weeks for both groups. Further research is needed to determine whether access to primary care for newly insured patients will endure over time. more...

Previous studies suggest that psychiatric patients mirror the behaviors of the staff members who treat them, but there is little empirical evidence about how staff dynamics affect patients over time. The goals of this study were to examine associations between: (1) team leader discipline and mutual respect among treatment team members; and (2) mutual respect among team members and improvements in patient quality of life. Two models were tested on data from psychiatric treatment teams within the US Veterans Administration. The first examined associations between the discipline of each team's emergent leader and the level of mutual respect among that team's members. The second model tested associations between mutual respect among staff and changes over time in patients’ quality of life. The subjects for model 1 were psychiatric staff members ( n = 785 ) whose responses were aggregated for team-level analyses ( n = 78 ). Mutual respect was highest in social worker-led teams and lowest in physician-led teams. The subjects for model 2 were 1638 seriously mentally ill patients in 44 of the units examined in the first model. When mutual respect among staff was greater, patients improved more over time in their satisfaction with the quality of their housing, relations with families, social life, and finances. Together, these analyses imply that mutual respect may improve patient outcomes and that leadership by some disciplines may facilitate such dynamics. In general, leaders may consider learning from other disciplines’ strengths to improve their impact. more...

Cross-functional teams (CFTs), also known as multidisciplinary teams, play an important role in the U.S. health care system (Fried, Topping, and Rundall 2000). Indeed, the IOM has recently identified improving the performance of CFTs as a major challenge for providers in the 21st century health system (IOM 2001). In mental health care, CFTs can help health providers effectively synthesize and apply knowledge from a variety of disciplines to the complex problems of treating the seriously mentally ill. By definition, CFTs are composed of individuals from different disciplines who have varied backgrounds and interpretive schemes for analyzing problems (Dougherty 1992). Relationships among CFT members are intended to be nonhierarchical, so that all members may contribute their knowledge according to situational demands rather than traditional organizational roles (Donellon 1993; Vinokur-Kaplan 1995). Compared with more traditional forms of organization, CFTs are associated with more creative solutions, better quality decisions, increased organizational effectiveness, and lower turnover rates among treatment staff (Wagner 1994; Dean, LaVallee, and McLaughlin 1999; Fried, Topping, and Rundall 2000). Teams also provide members with greater opportunities for learning and professional growth, a greater sense of empowerment (Kanter 1977; Edmondson, Bohmer, and Pisano 2001), and greater job satisfaction (Bettenhausen 1991). However, in order for CFTs to realize these potential benefits, there must be a high degree of cooperation among the team members so that knowledge is truly synthesized. Empirical research on the relationship between team process and team performance in health care settings is relatively scarce. Much of the research on health care teams has employed randomized control trials to assess team performance and effectiveness. Such research has treated teams as molar interventions and failed to address team processes specifically. Thus, it provides relatively limited understanding of what aspects of team process are responsible for positive or negative performance. On the other hand, quasi-experimental studies of health care CFT processes are cross-sectional and have largely failed to relate these processes to objective measures of team performance (Cohen and Bailey 1997). Our study attempts to address these gaps by examining the relationship between team processes and change in patient functional status, as measured through activities of daily living (ADL), in a sample of 40 CFTs in the Veterans Affairs (VA) mental health system. The ADL scale reflects clinician assessments of patient functioning and daily living skills in six domains: eating, bathing, grooming, dressing, transferring, and toileting. ADLs are used extensively in psychiatric treatment to evaluate the type of care patients require and evaluate care processes and outcomes (Hawes et al. 1997; Hirdes et al. 2002). The design of the current study made several advances possible. First, it employed a large sample of patients and evaluated how these patients changed in functional status over a protracted period. This avoided problems common in cross-sectional or short-term studies of team effectiveness, whereby patients of different functional abilities systematically select into different types of teams, or the period of observation is not sufficiently long to detect meaningful changes. Second, the study used multilevel methods to assess how team-level processes affected change in patient-level functional status. This approach permits the identification of differential effects of team care across categories of patients and avoids aggregation bias caused by summing or averaging outcome measures to the team level. Finally, the study controlled for individual patient characteristics that may have been associated with ADL scores and might otherwise have confounded the team process–ADL relationship. more...

Study objective We evaluate the effectiveness of an emergency department (ED)–based outreach program in increasing the enrollment of uninsured children. Methods The study involved placing a full-time worker trained to enroll uninsured children into Medicaid or the State Children's Health Insurance Program in an inner-city academic children's hospital ED. Analysis was carried out for outpatient ED visits by insurance status, average revenue per patient from uninsured and insured children, proportion of patients enrolled in Medicaid and State Children's Health Insurance Program through this program, estimated incremental revenue from new enrollees, and program-specific incremental costs. A cost-benefit analysis and breakeven analysis was conducted to determine the impact of this intervention on ED revenues. Results Five thousand ninety-four uninsured children were treated during the 10 consecutive months assessed, and 4,667 were treated during program hours. One thousand eight hundred and three applications were filed, giving a program penetration rate of 39%. Eighty-four percent of applications filed were resolved (67% of these were Medicaid). Average revenue from each outpatient ED visit for Medicaid was US$135.68, other insurance was US$210.43, and uninsured was US$15.03. Estimated incremental revenue for each uninsured patient converted to Medicaid was US$120.65. Total annualized incremental revenue was US$224,474, and the net incremental revenue, after accounting for program costs, was US$157,414 per year. Conclusion A program enrolling uninsured children at an inner-city pediatric ED into government insurance was effective and generated revenue that paid for program costs. more...

Cross-functional teams (CFTs) play an increasingly important role in health care. However, despite their potential, CFTs often fail to function effectively. This paper contributes to the literature in medical sociology by examining how the steep and well-defined hierarchy characteristic of the health occupations proves to be dysfunctional in the CFT setting. Previous research has shown that status differences among members of work teams negatively affect their functioning. Yet the specific mechanisms that connect variations in status to poor team functioning remain unclear. We hypothesize that it is the suppression of participation among low status team members that leads to poor CFT functioning. Our theoretical model integrates status characteristics theory and the value attainment theory of job satisfaction to link team members' statuses to participation in team decision-making and, ultimately, to their attitudes about the job. We use causal modeling to test our hypotheses. Our results indicate that relationships between health professionals defined in broader social contexts affect status, roles, and functions within CFTs, and these, in turn, affect the team's interpersonal processes. We suggest changes in organizational structure and in team leadership styles that might make CFTs more effective. more...

Previous studies using relational demography theory have hypothesized that being demographically dissimilar has a negative impact on individual perceptions of advancement opportunities. The authors investigate whether an organization’s social context, leaders’ characteristics, and geographic location offset, or even reverse, the negative effects of being dissimilar. Data were collected through two surveys: a 1995 survey of 2,252 employees from 139 treatment units in 38 Department of Veterans Affairs (VA) psychiatric hospitals, and a 1999 survey of the 38VA hospitals’ administrative offices. The authors used nested linear regression analysis to test the hypotheses. Unlike previous studies, the results indicate that the more dissimilar an individual is with regard to age andrace, the more positive his or her perceptions of advancement opportunities. They conclude that the equal employment opportunity policies pursued by public sector organizations, such as the VA, may alter the relationship between demographic dissimilarity and perceptions of advancement opportunities. more...

Causal modeling was used to explore the processes by which individual characteristics, job satisfaction, and intention to quit explain turnover among nursing personnel in 29 Department of Veterans Affairs (VA) long-term psychiatric settings. The sample consisted of 1,106 registered nurses (RNs), licensed practical nurses (LPNs), and nurses' aides. We conceptualized turnover as a multistage process linking social and experiential orientations, attitudes toward the job, the decision to quit, and the behavior of actually quitting. Intention to quit was the strongest direct predictor of turnover. Professional growth opportunities and workload were important indirect predictors of turnover. Dissatisfaction with work hazards and relationships with coworkers were both indirect and direct predictors of turnover. Attitudes towards the job varied by nursing group. LPNs and aides were less satisfied than RNs with autonomy and work hazards. RNs were more dissatisfied with workload. We conclude that strategies to promote retention need to address aspects of jobs tailored to specific nursing groups. more...

Many organizations are making a deliberate effort to use teams to carry out work as an alternative to more traditional, hierarchical approaches to defining jobs or supervising employees. The authors posit that structure and composition of work teams are likely to systematically affect group dynamics of such teams. Using the related frameworks of social identification theory and embedded intergroup relations theory, they examine the proposition that greater diversity of team member characteristics and larger team size negatively affect members' perceptions of team integration. Hypotheses were tested on 1,004 individuals working on 105 interdisciplinary treatment teams in a national sample of 29 Department of Veterans Affairs psychiatric hospitals. Five of six hypotheses received support for at least one of three dimensions of team integration examined in this article. The strongest support was found for the effects of diversity on perceptions of team functioning. Results are generally consistent with the basic premise of the embedded intergroup relations model: As teams become more diverse along most identity group and organizational group characteristics, intergroup relations among team members suffer and perceived level of team integration declines. The authors offer several suggestions about how managers and team leaders might use these findings to improve team integration. more...

Characteristics of individual mental health providers and of treatment settings were examined to determine their effects on providers' expectations about the improvement of patients with serious mental illness.The sample consisted of 1,567 treatment providers working in 107 inpatient and outpatient units or programs in 29 Veterans Affairs mental health facilities. They completed a questionnaire about their prognostic expectations and a broad range of attitudes toward job satisfaction, professional relations, and team functioning. Unit or program directors of all 107 units completed another questionnaire about the average functional ability of patients, unit workload, and unit size. Hierarchical linear modeling was used to assess the effects of both individual and unit-level attributes on providers' expectations of improvement in clinical symptomatology and social-functional skills of patients in their care.The providers had generally low expectations about the improvement of patients with serious mental illness. Expectations were higher among staff in units or programs that were smaller and that had an outpatient focus, a greater proportion of staff involved in the treatment team, and higher-functioning patients. Individual characteristics significantly associated with prognostic expectations were occupation, age, and membership on the treatment team.Prognostic expectations among providers of care to persons with serious mental illness vary with identifiable individual and unit or program characteristics. The latter may be amenable to manipulation and intervention to improve mental health providers' prognostic expectations. more...

There have been increasing calls for community–academic partnerships to enhance the capacity of partners to engage in policy advocacy aimed at eliminating health disparities. Community-based participatory research (CBPR) is a partnership approach that can facilitate capacity building and policy change through equitable engagement of diverse partners. Toward this end, the Detroit Community–Academic Urban Research Center, a long-standing CBPR partnership, has conducted a policy training project. We describe CBPR and its relevance to health disparities; the interface between CBPR, policy advocacy, and health disparities; the rationale for capacity building to foster policy advocacy; and the process and outcomes of our policy advocacy training. We discuss lessons learned and implications for CBPR and policy advocacy to eliminate health disparities. more...

The multiple and diverse perspectives, skills, and experiences inherent in community–academic partnerships make them uniquely positioned to educate policy makers and advocate for health equity. Effective communication tools are critical to successfully engage in the policy-making process. Yet few resources emphasize the development and use of practical tools for translating community-based participatory research (CBPR) findings into action. The purpose of this article is to describe a CBPR process for developing and using a one-page summary, or “one-pager,” of research findings and their policy implications. This article draws on the experience of the Healthy Environments Partnership (HEP), a community–academic partnership in Detroit, Michigan. In addition to describing these processes, this article includes a template for a one-pager and an example of a one-pager that was written for and presented to federal policy makers. more...

We present results of a study designed to analyze the marketing strategies of a national sample of health maintenance organizations (HMOs). We addressed the following questions: (a) Are HMO advertising strategies designed to appeal disproportionately to healthy seniors? That is, are marketing efforts attempting to skim off the profitable, low cost, healthier seniors? (b) Are certain features of HMOs' promotional campaigns more likely to attract healthier rather than sicker Medicare beneficiaries? Specifically, we report results of a content analysis of the HMO media marketing campaigns and describe the relation between marketing content and the health status of seniors who join or do not join the health plans. more...

The issue of selection bias was investigated using data from 22 HMOs who are enrolling Medicare beneficiaries under Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) at-risk contracts. The study differs from previously published analyses of this issue in that it deals with the current Medicare risk program (TEFRA) rather than with earlier Demonstration Programs; as an indicator of selection bias, it utilizes beneficiary functional health status at enrollment; and it examines selection not only at the mean of the health status distribution, but at the two tails (very disabled, very able) as well. For each of the participating HMOs, the functional health status of recent Medicare enrollees was compared with that of a control group of randomly chosen fee-for-service beneficiaries. None of the HMOs experienced adverse selection, whether measured in terms of overall (mean) health status of enrollees or in terms of the proportion of the very disabled population that chose to join. Nine of the 22 HMOs were considered to have experienced favorable selection on the basis of the mean health status of new enrollees. In addition, ten more HMOs were found to have experienced favorable selection in one or both tails of the health status distribution. Although a specific cause for the observed enrollment patterns is not identified, speculation is made on factors that may or may not contribute. Evidence suggests that beneficiary self-selection is probably a more important explanation of these patterns than purposeful actions of HMOs to discourage enrollment by sicker beneficiaries (i.e., "skimming"). more...

In order to address the social, physical and economic determinants of urban health, researchers, public health practitioners, and community members have turned to more comprehensive and participatory approaches to research and interventions. One such approach, community-based participatory research (CBPR) in public health, has received considerable attention over the past decade, and numerous publications have described theoretical underpinnings, values, principles and practice. Issues related to the long-term sustainability of partnerships and activities have received limited attention. The purpose of this article is to examine the experiences and lessons learned from three Urban Research Centers (URCs) in Detroit, New York City, and Seattle, which were initially established in 1995 with core support from the Centers for Disease Control and Prevention (CDC). The experience of these Centers after core funding ceased in 2003 provides a case study to identify the challenges and facilitating factors for sustaining partnerships. We examine three broad dimensions of CBPR partnerships that we consider important for sustainability: (1) sustaining relationships and commitments among the partners involved; (2) sustaining the knowledge, capacity and values generated from the partnership; and (3) sustaining funding, staff, programs, policy changes and the partnership itself. We discuss the challenges faced by the URCs in sustaining these dimensions and the strategies used to overcome these challenges. Based on these experiences, we offer recommendations for: strategies that partnerships may find useful in sustaining their CBPR efforts; ways in which a Center mechanism can be useful for promoting sustainability; and considerations for funders of CBPR to increase sustainability. more...

Many low-income children who are eligible for public sector health insurance remain uninsured. There are many barriers to enrolling these children, but one key issue is parents' reluctance to use the services of the local enrollment agency, which is usually the welfare office. The Eastside Access Partnership, a community-academic coalition on the Eastside of Detroit, addressed the problem of uninsured-but-eligible children through a variety of interventions focused on (1) enhancing community members' understanding of the enrollment process and (2) reducing institutional barriers to enrollment. One of these interventions addressed the institutional barriers by developing a customer service excellence training program for welfare caseworkers. The training program curriculum, which was developed following the principles of community-based participatory research, included extensive input from community residents, welfare agency staff, and academic researchers. The training sessions received positive evaluations from participants and agency executives. A more thorough evaluation of the project is under way. more...

There has been a resurgence in the call for greater racial and ethnic diversity in the health workforce. Researchers in health services have made the "business case" for diverse leadership of healthcare organizations, arguing that this will make these organizations more effective in serving diverse populations. Greater diversity in health management training programs will also have positive effects on their students. This article has three purposes: to discuss the importance of diversity in health management training programs; to describe the University of Michigan's Summer Enrichment Program (SEP), a program to increase the number of students of color who receive graduate training in health management; and to report the results of a survey of SEP alumni, conducted after the program's 15th year, which describe the graduate school and career experiences of 167 SEP alumni. Based upon the survey results, the SEP appears to have been very successful in enlarging the pool of students of color who attend graduate programs in health management and who embark on careers in the field. It has also had a very positive effect on diversity within the University of Michigan program. The implications of the Michigan experience and recent Supreme Court decisions for other graduate programs are discussed. more...

Health educators can play a critical role in bringing together the partners and resources to successfully make videos using principles of community-based participatory research (CBPR). This article is a “how-to” guide for making videos using community-based participatory research principles. The authors describe video-making and CBPR, then outline six steps on how to make a video using principles of CBPR: (a) engaging stakeholders, (b) soliciting funding and informed consent, (c) creation of shared ownership, (d) building cross-cultural collaborations, (e) writing the script together, and (f) pulling it all together: editing and music selection. Still photographs and key themes from the video A Bridge Between Communities are presented as a running case study to illustrate these steps. The article concludes with implications for health promotion research and practice. more...

Patterns of mental health are clearly associated with life circumstances, including educational and economic opportunities, access to safe and supportive neighborhoods, socially structured exposures to stressors and to supportive relationships. In this article, we examine the social and economic correlates of depressive symptoms among African American women residing within a predominantly African American urban neighborhood in Detroit, USA, with relatively few economic resources. We identify distinct stressors associated with financial strain, neighborhood social disorder (concern about police responsiveness, safety stress), and experiences of discrimination. We test the extent to which each of these stressors mediates relationships between household income, length of residence in the neighborhood, social support and depressive symptoms. Our results suggest that for women in this racially segregated area with a high concentration of poverty, relationships between household income and symptoms of depression are partially mediated by financial stress and social support, but that stressors associated with neighborhood disorder and discrimination influence depressive symptoms independent of household income. Furthermore, we find that length of residence in the neighborhood is negatively associated with financial stress and positively associated with police stress and social support, with no significant net effect on symptoms of depression. We conclude that higher household income may help reduce symptoms of depression by reducing financial stress and strengthening social support even within neighborhoods with high concentrations of poverty. However, increased household income does not protect African American women residing in a high poverty community from distress associated with neighborhood disorder or experiences of discrimination. more...

There is increasing research evidence that stressors in the social and physical environment (e.g., poverty, inadequate housing, air pollution, and racism) are associated with poor health outcomes. Given the complex set of determinants of health status, the disproportionate burden of disease experienced within marginalized communities, and the limited effectiveness of traditional prevention research, particularly within communities of color, there have been growing calls for more comprehensive and participatory approaches to public health research and practice. The purpose of this article is to describe and analyze the process of establishing, implementing, and evaluating the Detroit Community-Academic Urban Research Center (URC), a community-based participatory research (CBPR) partnership involving community-based organizations, a local health department, academia, and an integrated health care system. Lessons learned and recommendations for creating effective CBPR partnerships are presented. more...

This study examined how different measures of individual perceptions of community social dynamics relate to each other and how these measures relate to self-reported general health and depressive symptoms. Results of a principal components analysis conducted to investigate the interrelationships between these individual measures suggest that these measures measure separate phenomena. In addition, in results of multiple-regression analyses conducted to examine associations between the various measures of individual perceptions of community social dynamics and the dependent variables of self-reported general health and depressive symptoms, sense of community, perceived neighborhood control, and neighborhood participation were all associated with the outcome variables in separate regression models. In a regression model with these three variables added to control variables, only sense of community was significantly, albeit modestly, associated with depressive symptoms and self-reported general health. more...

There has been a continuing public debate about assisted suicide and the proper role, if any, of physicians in this practice. Legislative bans and various forms of legalization have been proposed.We mailed questionnaires to three stratified random samples of Michigan physicians in specialties likely to involve the care of terminally ill patients: 500 in the spring of 1994, 500 in the summer of 1994, and 600 in the spring of 1995. Similar questionnaires were mailed to stratified random samples of Michigan adults: 449 in the spring of 1994 and 899 in the summer of 1994. Several different questionnaire forms were used, all of which included questions about whether physician-assisted suicide should be banned in Michigan or legalized under certain conditions.Usable questionnaires were returned by 1119 of 1518 physicians eligible for the study (74 percent), and 998 of 1307 eligible adults in the sample of the general public (76 percent). Asked to choose between legalization of physician-assisted suicide and an explicit ban, 56 percent of physicians and 66 percent of the public support legalization, 37 percent of physicians and 26 percent of the public preferred a ban, and 8 percent of each group were uncertain. When the physicians were given a wider range of choices, 40 percent preferred legalization, 37 percent preferred "no law" (i.e., no government regulation), 17 percent favored prohibition, and 5 percent were uncertain. If physician-assisted suicide were legal, 35 percent of physicians said they might participate if requested--22 percent would participate in either assisted suicide or voluntary euthanasia, and 13 percent would participate only in assisted suicide. Support for physician-assisted suicide was lowest among the strongly religious.Most Michigan physicians prefer either the legalization of physician-assisted suicide or no law at all; fewer than one fifth prefer a complete ban on the practice. Given a choice between legalization and a ban, two thirds of the Michigan public prefer legalization and one quarter prefer a ban. more...

The problems facing the U.S. health care system are not new; they have been discussed for the last 60 years. The problems have not been solved because, due to fears of government involvement, we have been reluctant to impose central planning and management on the system. Reliance on the free market and fee-for-service reimbursement to allocate health resources, to contain costs and to determine who has health insurance has failed. The result is that the U.S. spends more per capita on health services than any other country in the world, but lags behind many other countries on such health indicators as life expectancy and infant mortality. Several criteria for evaluating proposals for health reform are offered and ten such proposals are discussed. It is likely that, in the short run, the U.S. will adopt reforms that require the least change in the current system. However, these changes will not address adequately the fundamental problems with the system and, ultimately, major changes will have to be undertaken. [This article is followed by an editorial by Dr. Jonathan Trobe relating its concepts to the objectives set forth in the recently proposed Clinton Health Plan.] more...

The research evidence indicates that health maintenance organizations (HMOs) participating in the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) At-Risk Program tend to experience favorable selection. Although favorable selection might result from patient decisions, a common conjecture is that it can be induced by HMOs through their marketing activities. The purpose of this study is to examine the relationship between HMO marketing strategies and selection bias in TEFRA At-Risk HMOs. A purposive sample of 22 HMOs that were actively marketing their TEFRA programs was selected and data on organizational characteristics, market area characteristics, and HMO marketing decisions were collected. To measure selection bias in these HMOs, the functional health status of approximately 300 enrollees in each HMO was compared to that of 300 non-enrolling beneficiaries in the same area. Three dependent variables, reflecting selection bias at the mean, the low health tail, and the high health tail of the health status distribution were created. Weighted least squares regressions were then used to identify relationships between marketing elements and selection bias. Subject to the statistical limitations of the study, our conclusion is that it is doubtful that HMO marketing decisions are responsible for the prevalence of favorable selection in HMO enrollment. It also appears unlikely that HMOs were differentially targeting healthy and unhealthy segments of the Medicare market. more...

To the Editor: Physician-assisted suicide and active euthanasia are topics of contentious debate in Michigan. After Dr. Jack Kevorkian assisted in a number of highly publicized suicides, the state ... more...

Actuarial factors currently comprising Medicare's HMO capitation formula, the Adjusted Average Per Capita Cost (AAPCC), are considered by many researchers to be inadequate as predictors of future period health care costs. While it is often suggested that the formula should incorporate beneficiary health status, no measure of health status suitable for this purpose has yet been identified. The authors present initial results from a study of 1,934 randomly selected Medicare beneficiaries in Michigan. Beneficiaries were surveyed to obtain data on several alternative measures of health status. Medicare claims were used to estimate beneficiary health care costs for periods before and after the survey. In regressions on future period Medicare payments, equations including the AAPCC factors plus a health status measure achieved R2 values ranging from 0.013 to 0.072, depending on the health status measure, compared with an R2 value of 0.003 for the equation with AAPCC factors alone. more...

In studies of large elderly populations, two types of measures of physical health status, perceived health and functional health, are commonly used. Although they represent very different conceptions of health, these two types of measures appear often to be used interchangeably. In this paper, we examine changes over time in self-reported measures of perceived health and functional health for a sample of Medicare beneficiaries. By investigating the patterns of change in the two measures for different subgroups of the population, we are able to draw inferences about the appropriateness of each type of measure for specific administrative and/or research situations. The perceived health status measure appears suitable for descriptive studies of the health of elderly populations, while the greater stability of functional health makes this type of measure generally more appropriate in studies investigating relationships between an individual's physical health status and subsequent behavior. more...

The accurate measurement of physician job satisfaction in organized practice settings is important for both policy and administrative purposes. Previous efforts to measure physician job satisfaction have been unsatisfactory because of either conceptual or methodologic weaknesses. New measures of physician job satisfaction were developed and field tested on a population of physicians working in highly bureaucratic settings--prison health programs across the United States. Analysis of the measures demonstrated their reliability, validity, and ability to predict physicians' intentions to leave the job. The measures can serve to identify elements of the work setting that need to be changed to improve physician job satisfaction. more...

This report presents the results of 210 cases over a 10-year period using PORPs, TORPs, and notched incus homografts (NIH), for ossicular reconstruction in chronic ear surgery. There were 192 adults and 18 children. The surgical technique utilized temporalis fascia in an underlay technique with canal skin covering the outer surface of the fascia. Intact canal wall mastoid-tympanoplasty, as a one-stage procedure, was used for most cases. Homograft nasal cartilage was placed between the Plasti-Pore prosthesis and the graft. Notched incus homografts were prepared prior to surgery and stored in 4% formalin. There were 149 mastoid-tympanoplasties and 61 tympanoplasties performed. Revision of our cases was performed in 16.6%. Within 3 months of surgery, 86% of adults, and 44% (8/18) of children had dry, healed ears free of disease. The graft take rate was 96%. In adults, a total of 99 NIH, 50 TORPs, and 43 PORPs were implanted. In adults, the closure of the air-bone gap to 20 dB or less occurred in 58% using TORPs, 67% using PORPs, 76% using NIH-Partial replacement, and 20% using NIH-Total replacement. Excluding the cases that failed for reasons other than conductive hearing loss, the results improved to 69% for TORPs, 77% for PORPs, 77% for NIH-P, and 27% for NIH-T. In adults, the extrusion rate was 5.5% for Plasti-Pore and 3% for NIH. In children, the extrusion rate was 17% for Plasti-Pore prostheses. From this study, it appears that PORPs and TORPs with homograft nasal cartilage are satisfactory prostheses for chronic ear surgery in adults. In children, Plasti-Pore prostheses should be avoided unless the ear is healed, aerated, and stable. NIHs are good prostheses when the stapes is intact, but they are inferior to the TORP when placed on the footplate. Also, the NIH requires preparation prior to surgery and may be difficult to obtain. We plan to continue using PORPs and TORPs in chronic ear surgery until a better technique is found, or the complication rate becomes unacceptable. more...